The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

hyperglycemia

Urinary retention

Respiratory failure

Hypertension

Answer and Explanation

The Correct Answer is C

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

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Correct Answer is B

Explanation

A) Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest:
This approach is inappropriate for a client with bacterial pneumonia. While oxygen therapy may be necessary for some clients, administering a cough suppressant in this scenario is counterproductive. Pneumonia often leads to the accumulation of secretions, and suppressing the cough would prevent the client from clearing mucus from their airways, potentially worsening the condition. Bedrest is generally indicated, but it should not be the sole intervention.

B) Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing:
This is the most appropriate plan of care. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways, which is crucial in pneumonia. Antibiotics are necessary to treat the bacterial infection causing pneumonia. Facilitating adequate coughing helps the client expel secretions, reducing the risk of airway obstruction and improving oxygenation. Coarse rhonchi indicate the presence of mucus or secretions, which should be cleared with effective coughing.

C) Decrease activity, increase bronchodilator use, and encourage pursed lip breathing:
Decreasing activity is generally appropriate for a client with pneumonia to reduce fatigue, but increasing bronchodilator use is not typically indicated unless there is underlying bronchospasm, such as in asthma or COPD. Pursed lip breathing can help improve ventilation, but it is more beneficial for clients with obstructive airway diseases, not primarily for those with bacterial pneumonia. Therefore, this option does not address the immediate needs of the client.

D) Place in prone position, begin steroid therapy, and monitor glucose levels:
While prone positioning is helpful in some conditions like acute respiratory distress syndrome (ARDS), it is not routinely used for bacterial pneumonia unless the client has severe hypoxemia and requires advanced respiratory support. Steroid therapy is generally not indicated for bacterial pneumonia unless there is a specific inflammatory component (such as a superimposed condition like asthma or COPD). Monitoring glucose levels may be important in clients on steroid therapy, but this is not a primary concern in the treatment of bacterial pneumonia.

A. Weighing the client at the same time every day B. Assuring hourly urine output of at least 25 mL per hour C. Maintaining strict bedrest for the first 24 hours D. Providing pain control and reducing oxygen demand

Correct Answer is D

Explanation

A. Weighing the client at the same time every day:
While daily weights are important for monitoring fluid status (especially in patients at risk for heart failure or fluid retention), it is not the highest priority in the immediate post-MI period. Weighing the client daily can be useful to track fluid accumulation, but addressing the client’s pain management and oxygenation needs takes precedence in the acute phase of an MI.

B. Assuring hourly urine output of at least 25 mL per hour:
Maintaining adequate urine output (typically around 30 mL per hour) is important to assess renal perfusion and fluid balance, especially if the patient is at risk for renal insufficiency or cardiogenic shock. However, this is not the highest priority immediately following an MI. The first priority is managing the oxygen supply to the heart, and addressing pain and reducing myocardial oxygen demand is more crucial in the acute phase to prevent further damage.

C. Maintaining strict bedrest for the first 24 hours:
Strict bedrest may have been a common practice in the past for patients following an MI, but current guidelines emphasize early mobilization and gradual activity as tolerated to prevent complications like deep vein thrombosis (DVT), pulmonary embolism (PE), and muscle deconditioning. While some degree of rest may be necessary immediately after an MI, the priority is to control pain and reduce oxygen demand, not strictly maintain bedrest. Prolonged immobility is not recommended in the modern management of MI unless there are specific contraindications.

D. Providing pain control and reducing oxygen demand is the most critical intervention in the acute phase of an anterior wall MI. Effective pain relief helps to reduce sympathetic stimulation, which decreases heart rate, blood pressure, and myocardial oxygen demand, preventing further myocardial injury and improving outcomes. This is essential for stabilizing the client early in their post-MI course.

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Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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